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经颈静脉肝内门体分流术治疗肝细胞癌合并食管胃底静脉曲张破裂出血的效果分析

高翔 张晓丰 曹伊敏 陈金军 罗小琴

引用本文:
Citation:

经颈静脉肝内门体分流术治疗肝细胞癌合并食管胃底静脉曲张破裂出血的效果分析

DOI: 10.12449/JCH241016
基金项目: 

国家自然科学基金 (82300698);

国家自然科学基金 (82370614)

伦理学声明:本研究方案经由南方医科大学南方医院伦理委员会审批,批号:NFEC-2021-005。所有患者均知情并签署知情同意书。
利益冲突声明:本文不存在任何利益冲突。
作者贡献声明:高翔负责数据收集,统计学分析,绘制图表,撰写文稿; 张晓丰负责指导研究思路,设计论文框架,论文修改;曹伊敏负责随访患者,数据收集;罗小琴负责数据收集,指导研究思路,指导文章撰写;陈金军负责确定写作思路,指导文章撰写及最后定稿。
详细信息
    通信作者:

    陈金军, chjj@smu.edu.cn (ORCID: 0000-0003-4275-9149)

    罗小琴, lingdu618@126.com (ORCID: 0009-0002-3907-1087)

Efficacy of transjugular intrahepatic portosystemic shunt in treatment of hepatocellular carcinoma comorbid with esophagogastric variceal bleeding

Research funding: 

National Natural Science Foundation of China (82300698);

National Natural Science Foundation of China (82370614)

More Information
  • 摘要:   目的  评估经颈静脉肝内门体分流术(TIPS)预防肝细胞癌(HCC)合并食管胃底静脉曲张破裂出血患者发生再出血的疗效,并探索影响预后的因素。  方法  回顾性分析2019年7月—2023年4月南方医科大学南方医院增城院区收治的HCC合并食管胃底静脉曲张破裂出血并接受TIPS治疗的35例患者的临床资料。Kaplan-Meier曲线评估TIPS术后再出血率及生存率。Cox回归模型分析患者术后再出血及生存的影响因素。  结果  所有患者TIPS手术均在技术上成功。中位随访时间16.4个月。随访期间11例(31.4%)患者发生食管胃底静脉曲张再出血,1个月、3个月和1年再出血率分别为5.7%、17.1%和28.6%。TIPS术后再出血的独立预测因子为WBC[风险比(HR)=1.31,95%CI:1.04~1.64,P=0.021]、肿瘤数目≥3个(HR=35.68,95%CI:1.74~733.79,P=0.021)和术前门静脉压力梯度(HR=0.85,95%CI:0.73~0.99,P=0.032)。术后发生分流道失功5例。随访期间,共有19例患者死亡,中位生存期为9.6个月;TIPS术后生存的独立预测因子为门静脉癌栓(PVTT)(HR=7.04,95%CI:1.31~37.78,P=0.023)、血清TBil(HR=1.02,95%CI:1.00~1.03,P=0.042)和血清Alb水平(HR=0.82,95%CI:0.72~0.94,P=0.004)。  结论  TIPS可作为预防HCC患者食管胃底静脉曲张再出血的治疗选择;在WBC、TBil较高或伴有PVTT患者中,患者预后较差,应谨慎决定是否进行TIPS治疗。

     

  • 图  1  影响HCC患者再出血因素的Kaplan-Meier曲线

    Figure  1.  Kaplan-Meier curve of factors affecting rebleeding in patients with HCC

    图  2  影响 HCC患者死亡因素的Kaplan-Meier曲线

    Figure  2.  Kaplan-Meier curve of factors affecting mortality in patients with HCC

    表  1  35例患者基线特征

    Table  1.   Patients’ baseline characteristics

    指标 数值
    年龄(岁) 56.0(52.0~63.0)
    男性[例(%)] 33(94.3)
    肝病病因[例(%)]
    乙型肝炎 27(77.1)
    丙型肝炎 3(8.6)
    其他 5(14.3)
    门静脉血栓[例(%)] 10(28.6)
    PVTT[例(%)] 12(34.3)
    既往肝性脑病[例(%)] 2(5.7)
    实验室指标(TIPS术前)
    WBC(×109/L) 5.0(3.5~9.1)
    ALT(U/L) 23.4(18.3~52.9)
    TBil(μmol/L) 29.7(18.6~38.9)
    Alb(g/dL) 31.7(29.0~35.4)
    SCr(μmol/L) 75.2(65.0~122.9)
    PT(s) 17.2(14.9~19.3)
    AFP(ng/mL) 11.8(5.6~99.7)
    肿瘤数目[例(%)]
    1个 14(40.0)
    2个 11(31.4)
    ≥3个 10(28.6)
    肿瘤最大直径(mm) 40.0(24.0~65.0)
    MELD评分(分) 12.7(10.6~20.2)
    Child-Pugh分级[例(%)]
    A级 9(25.7)
    B级 23(65.7)
    C级 3(8.6)
    巴塞罗那分期[例(%)]
    A期 15(42.9)
    B期 13(37.1)
    C期 4(11.4)
    D期 3(8.6)
    急诊TIPS[例(%)] 10(28.6)
    TIPS术前PPG(mmHg) 22.5(18.0~25.3)1)
    TIPS术后PPG(mmHg) 9.0(8.0~12.0)1)
    PPG下降率≥50% 24(68.6)1)

    注:1)1例患者未测得术前及术后门静脉压力。PVTT,门静脉癌栓;SCr,血肌酐;PT,凝血酶原时间;AFP,甲胎蛋白。

    下载: 导出CSV

    表  2  影响 HCC患者再出血的单因素和多因素Cox分析

    Table  2.   Univariate and multivariate Cox analysis affecting rebleeding in patients with HCC

    指标 单因素分析 多因素分析
    HR(95%CI P HR(95%CI P
    PVTT 1.95(0.55~6.89) 0.300
    实验室指标(TIPS术前)
    WBC 1.10(1.00~1.20) 0.044 1.31(1.04~1.64) 0.021
    TBil 1.00(0.97~1.02) 0.859
    Alb 0.96(0.87~1.06) 0.437
    肿瘤数目
    1个 1.00
    2个 1.05(0.21~5.22) 0.954 3.06(0.25~37.60) 0.382
    ≥3个 2.78(0.66~11.65) 0.162 35.68(1.74~733.79) 0.021
    Child-Pugh分级
    A级 1.00
    B级 0.68(0.18~2.55) 0.566
    C级 1.63(0.29~9.01) 0.577
    急诊TIPS 2.25(0.68~7.43) 0.184
    TIPS术前PPG 0.93(0.82~1.04) 0.208 0.85(0.73~0.99) 0.032
    TIPS术后PPG 0.94(0.82~1.07) 0.341

    注:PVTT赋值:有=1,无=0;急诊TIPS赋值:行急诊TIPS=1,未行急诊TIPS(即择期TIPS)=0。

    下载: 导出CSV

    表  3  影响 HCC患者死亡的单因素和多因素Cox分析

    Table  3.   Univariate and multivariate Cox analysis affecting death in patients with HCC

    指标 单因素分析 多因素分析
    HR(95%CI P HR(95%CI P
    男性 5.17(1.11~24.13) 0.037 3.12(0.04~261.77) 0.615
    门静脉血栓 3.10(1.25~7.67) 0.015 1.64(0.42~6.39) 0.475
    PVTT 3.80(1.48~9.75) 0.005 7.04(1.31~37.78) 0.023
    既往肝性脑病 3.96(0.85~18.46) 0.080
    实验室指标(TIPS术前)
    WBC 1.07(0.99~1.16) 0.109
    TBil 1.01(1.00~1.02) 0.005 1.02(1.00~1.03) 0.042
    Alb 0.94(0.87~1.01) 0.097 0.82(0.72~0.94) 0.004
    Cr 1.01(1.00~1.01) 0.043 1.01(1.00~1.02) 0.139
    PT 1.12(1.00~1.25) 0.043
    INR 5.16(1.05~25.37) 0.044 1.18(0.07~20.50) 0.910
    MELD评分(分) 1.11(1.03~1.20) 0.009
    Child-Pugh分级
    A级 1.00
    B级 4.69(1.06~20.77) 0.042 1.61(0.26~10.04) 0.611
    C级 7.37(1.18~45.89) 0.032 0.84(0.03~20.52) 0.915
    TIPS术前PPG 1.04(0.96~1.13) 0.344

    注:门静脉血栓赋值:有=1,无=0;PVTT赋值:有=1,无=0;既往肝性脑病赋值:有=1,无=0。

    下载: 导出CSV
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